The Facial Platysma and Its Underappreciated Role in Lower Face Dynamics and Contour Ada R.T. de Almeida, MD,* Alessandra Romiti, MD,* and Jean D.A. Carruthers, MD, FRCSC, FRC (OPHTH)† BACKGROUND The platysma is a superficial muscle involved in important features of the aging neck. Vertical 03/01/2019 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FlQBFFqx6X8f2YacK2KomzwZi55X7VWV75FoKYjzDDE= by https://journals.lww.com/dermatologicsurgery from Downloaded Downloaded bands, horizontal lines, and loss of lower face contour are effectively treated with botulinum toxin A (BoNT-A). However, its pars facialis, mandibularis, and modiolaris have been underappreciated. from OBJECTIVE To demonstrate the role of BoNT-A treatment of the upper platysma and its impact on lower face https://journals.lww.com/dermatologicsurgery dynamics and contour. MATERIAL AND METHODS Retrospective analysis of cases treated by an injection pattern encompassing the facial platysma components, aiming to block the lower face as a whole complex. It consisted of 2 intramuscular injections into the mentalis muscle and 2 horizontal lines of BoNT-A injections superficially performed above and below the mandible (total dose, 16 onabotulinumtoxinA U/side). Photographs were taken at rest and during motion (frontal and oblique views), before and after treatment. by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FlQBFFqx6X8f2YacK2KomzwZi55X7VWV75FoKYjzDDE= RESULTS A total of 161 patients have been treated in the last 2 years with the following results: frontal and lateral enhancement of lower facial contour, relaxation of high horizontal lines located just below the lateral mandibular border, and lower deep vertical smile lines present lateral to the oral commissures and melo- mental folds. CONCLUSION The upper platysma muscle plays a relevant role in the functional anatomy of the lower face that can be modulated safely with neuromodulators. A.R.T. de Almeida has been a consultant to Allergan Inc. and Merz, and participated in clinical trials for Allergan and Galderma. A. Romiti has been paid to give lectures for Galderma. J.D.A. Carruthers has been paid to do research by Allergan, Inc., Medicis, Inc., Ipsen Pharma, Merz GmbH, and has been a consultant to Allergan, Inc., Medicis, Inc., Ipsen Pharma, Merz GmbH, and Solstice Neurosciences. he muscular anatomy involved in the lower face The use of botulinum toxin A (BoNT-A) in this region Tmuscles of facial expression is complex and is considered as an advanced technique and gained includes the orbicularis oris (OO), depressor angulis acceptance after years of experience in the upper face. oris (DAO), depressor labii inferioris (DLI), risorius As with the upper facial areas, it can be indicated for (R), masseter (MA), mentalis (M), and platysma (P) the treatment of specific muscles alone or several muscles. It is known that not only persistent muscles combined as a whole lower face complex. on contractions wrinkle the skin, but the increased Usually, to address mouth frown and melomental 03/01/2019 platysmal resting tone is also implicated in the folds (Marionette Lines), the depressor anguli oris is muscular role of senescence.1 Such changes can be injected. Mentalis is the target when correcting or modified by neuromodulators, either alone or in alleviating a mental crease and/or a peau d’orange combination with other treatment modalities (e.g., appearance over the chin,2 whereas injections into the fillers, resurfacing with laser and energy-based devices, MA can alter the shape of the jawline by reducing surgery). muscle thickness and bulk.3 *Dermatologic Clinic, Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil; †Department of Ophthalmology and Visual Science, University of British Columbia, Vancouver, British Columbia, Canada © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1076-0512 · Dermatol Surg 2017;43:1042–1049 · DOI: 10.1097/DSS.0000000000001135 1042 © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. DE ALMEIDA ET AL Figure 1. Cadaver dissection showing the depressor angulis oris, and platysma pars mandibularis (left). The latter, when contracted, produces high parallel lines and wrinkles located just below the lateral mandibular border (right). The platysma is a broad flat muscle that covers the were horizontally injected along each mandible and anterior and lateral aspects of the neck. It rises from into the upper portion of the posterior platysmal the superficial fascia over the upper chest and ascends band.11,12 The result was a visible release of the superior-medially from the neck to insert into 3 points: platysma muscle’sdownwardpullingandjawline medially into the mentum; centrally into the perios- recontouring. teum of the ramus of the mandible; and laterally to the OO, DAO, and R muscles overlying subcutaneous On the other hand, whereas useful when adequately tissue.4 Its anterior fibers from both sides may cross indicated, the Nefertiti Lift technique does not address each other at the midline, forming various patterns of the anterior platysma fibers. Because only the lateral decussation, whereas complete separation may also upper half and the posterior platysma band are trea- occur.5,6 When the upper and lower portions of the ted, the untreated anterior fibers may be recruited platysma contract, they pull the skin to the center of during neck contraction, resulting in local wrinkling, the muscle like a compressed accordion, forming banding worsening, and loss of anterior facial con- horizontal neck lines. tour. To avoid these problems, many BoNT-A experts use their own technical variations of the method, Most BoNT-A injection techniques have targeted the adapted to each patient’s individual needs. platysmal bands and horizontal necklines (like “laces”). First described by Brandt and Bellman, not Some described techniques are a single injection only the tightening of the neck, but also some kind of sequence performed horizontally at 3 to 4 sites at the jawline recontouring was noticed by these authors.7 mandibular line (Dr. A. Romiti, MD, personal com- To achieve the results, though, high doses of BoNT-As munication, June 6, 2013), a technique using a single were needed (up to 200 units of onabotulinumtox- injection site with 20U to 30U onabotulinumtoxinA inA), and side effects related to the toxin diffusion to per side,13 or an entire neck treatment of minute adjacent muscles were also reported. This fact made intradermal doses of BoNT-A, with a total dose of 60 experts recommend reducing the total dosage used, to to 80 onabotulinumtoxinA U (Dr. Woffles Wu avoid complications.8–10 Microbotox technique).14 Focusing specifically on jawline redefinition, Levy The objective of this article is to review the functional described the “Nefertiti lift,” where individuals anatomy and to evaluate the role of BoNT-A 43:8:AUGUST 2017 1043 © 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. FACIAL PLATYSMA AND BONT-A treatment of the upper platysma muscle and its impact lateral to the DAO. Its contraction contributes to the on the lower facial dynamics and contour. appearance of lower vertical deep smile lines located laterally to the oral commissures and laterally to the melomental folds.15 (Figure 3). Upper Platysma Functional Anatomy Although appearing in face and neck drawings in Material and Methods anatomic papers, especially about botulinum toxin, the upper platysma location and function are fre- Study Design quently neglected or forgotten. It is classically described as having 3 parts: This is a retrospective, open label study performed at 3 centers, which complied with the ethical rules of the Platysma pars mandibularis, which inserts onto the 2000 Declaration of Helsinki. To achieve complete lower border of mandible and onto the skin and sub- relaxation of the upper platysma area, the entire lower cutaneous plane of the lower face, with some fibers face was considered as a single region and treated as interdigitating with the DAO. Its contraction forms a “lower face complex.” For this reason, a standard oblique and horizontal parallel lines and wrinkles that injection pattern was chosen and applied for all subjects. appear high in the neck just below the lateral man- dibular border and above the necklace lines (Figure 1). Patient Selection and Documentation Platysma pars labialis, which travels deep to DAO, re- Patients aged 18 years and older, seen at the Derma- emerges medially to it, interdigitates and blends to tologic Clinic of Hospital do Servidor Público OO, DLI, and mentalis muscles, and in some cases, Municipal de São Paulo and the private clinics of the occupies the space between DLI and DAO. Its con- first 2 authors, were selected. Subjects were invited to traction may be related to horizontal lines located participate if they had investigator identified, loss of below the oral commissures and lower lip (Figure 2). lower face contour, and/or lower face and upper neck wrinkles and lines, during lower face animation. Platysma pars modiolaris, which includes all of the Upper neck was defined as the region located just remaining fibers of upper platysma that are postero- below the mandibular border. There were no Figure 2. Cadaver dissection showing the depressor